ABX

abbreviation for antibiotics

Allopathic Medicine

the idea that chemistry is the root of most medical problems and that the use of drugs to restore normal chemistry levels will help cure illnesses

Alternative Therapy

therapies that are not accepted by 'traditional' medicine. Including but not limited to: acupuncture, herbal remedies, meditation, etc

Applications

refers to the separate components of a electronic medical system including charting, billing, scheduling, document management, and tracking boards

ASP (Application Service Provider)

a company that provides a hosted software application on-demand through a web-browser

Assessment Section

the patient record section where the provider documents their PT diagnoses and differentials, problem list, goals, and prognosis of treatment plan

Automated Scoring

calculations are done within the application for appropriate algebraic equations for the user automatically. These can be independent numbers automatically calculated to come up with a total (e.g. - body mass index) or can be calculations used to score a particular evaluation test.

Balance Forward

the accounting reference for the amount outstanding on an account transferred from another billing system

BFM (Billing Feeds Manager)

integration tool allowing WebPT to link with multiple billing companies for the exchange of the billing information

BMI (Body Mass Index)

a calculation based on height and weight. Used to demonstrate how much effect a person's weight is on their health

Capitated Insurance Plans (Capitation)

Insurance plans that pay providers a set amount per month per patient vs. basing payment on a specific service rendered. These patients will only owe a nominal copay at the time of service. Capitation creates risk for a practice because it is then up to the provider to make sure they manage their patients problems within the amount they are receiving. They can be penalized for referring patients out to more expensive specialists, so the emphasis is very much on preventive care.

Chart Note/Progress Note

a document written by the provider which describes the details of the patients encounter

Chief Complaint (CC:)

is the reason a patient is being seen in their own words

Chronic Medical Problems

a list of a patient's ongoing long-term medical issues

CLIA (Clinical Laboratory Improvement Act)

is the common term for the laws governing laboratory tests and the facilities in which they are conducted. CLIA certification is usually required for a lab to be reimbursed. The CLIA number assigned to a lab will need to be included for billing of certain lab tests and is entered in the setup of an electronic billing system.

CMS (Centers for Medicare and Medicaid Services)

government regulatory board for Medicare and Medicaid

Conversion Factor

a dollar value to four decimal places used as a multiplier by HCFA when calculating reimbursement rates. The CF is updated annually to allow for inflation. Many payors will base their reimbursement rates on a CF slightly different from Medicare's but maintain the other multipliers.

Copay

a set amount that is the patients portion of an office visit due at the time of service. The copay can change depending on the type of visit

CPT Code

A nationally recognized five-digit number used to represent a service provided by a healthcare provider

CPT® (Current Procedural Terminology)

the standard procedure codes used by the industry (i.e. EKG)

Cross Platform (platform independent)

software application that works on more than one system platform e.g. Mac, Windows, Unix, etc)

Current Medications

a list of all medications taken regularly by a patient

D.O. (Doctor of Osteopathy)

Similar training to M.D., but focus on the body structure (bones, nerves and muscles) in the belief that problems with these are often the causes of illness and manipulation can be a cure. They attend specific osteopathic schools that cover much the same information as traditional medical schools, in addition to manipulative therapy, and are qualified to treat the same illnesses. Most D.O.s specialize in primary care disciplines and practice exactly like M.D.s while others concentrate on herbal and alternative remedies.

Deductible

the amount a patient must pay out pocket during a year of insured coverage before the insurance will begin to pay claims. Most group plans only have a deductible or copay for normal office visits. Deductibles are almost always due for hospital and other visits.

Differential Diagnosis (DDX)

is a list of possible diagnoses. For example, if a patient was given a general diagnosis of chest pain, but the provider had ordered additional tests to rule out other more specific diagnoses, they would list the differential diagnosis as a way of notating that they are considering several possibilities. Documenting differential diagnoses helps substantiate higher coding for medical decision-making.

DME (Durable Medical Equipment)

medical equipment that Is used to serve a medial purpose and can withstand repeated use(e.g. - wheelchairs, crutches or nebulizers). These are specific billed using specific HCPCS codes called E codes.

Document Imaging

the process of converting paper documents into electronic format usually through a process of scanning

Document Management

the process of scanning, categorizing and storing vital patient documents

Dx

the standard abbreviation for diagnosis

E Codes

specific HCPCS codes used for DME

E&M (Evaluation and Management) Codes

the code used to define a visit type (i.e. level 3 office visit, newborn initial evaluation, etc.). E&M codes are a subset of CPT® codes

EDI (Electronic Data Interchange)

electronic communication between two parties, generally for the filing of electronic claims to payers

eDoc (External Documents)

WebPT's solution for storing outside documents (patient consent forms, insurance card copies, etc); member simply uploads the document using a scanner and 'files' the created PDF into the patient chart

EMR (Electronic Medical Records) also known as EHR (Electronic Health Records) or CPR (Computerized Patient Record)

a computerized record of patients clinical, demographic and administrative data including a patient’s past, present and future clinical information, stored electronically

EPSDT (Early and Periodic Screening, Diagnosis and Testing)

medicaid uses this term for well visits, immunizations and other standard childhood wellness standards

Family History

a list of the patient's immediate family medical history including the chronic medical problems of parents, siblings, grandparents, etc

Fee Schedules

A comprehensive list of all CPT® and HCPCS codes and their corresponding charges. Can vary based on insurance. Fee schedules are usually associated with a particular payor and reflect the reimbursement rates negotiated under the contract.

GPCI (Geographic Practice Cost Index)

A regional weight assigned to a Medicare locality that takes into account the cost of delivering services in that area. Each RVU component is given a specific weight, with 1.00 being the mean (therefore .9 would reflect a lower cost base, and 1.1 would be higher). GPCIs are a multiplier in the equation used to calculate Medicare allowable reimbursement rate.

Guarantor

the person ultimately responsible for a bill after insurance

GUI (Graphical User Interface)

the programs interface/design that all comes together to help the user navigate the program

HCFA (1500) Form

the standard insurance claim form used by most, but not all, insurances to submit paper claims

HCFA (Health Care Financing Administration)

is the government body that controls and directs legislation for government sponsored health coverage (Medicare, Medicaid). They are responsible for much of the reimbursement rates upon which other payors will base their rates.

HCFA-1450

commonly known as the UB-92 (Universal Bill). This is also an insurance claim form, but is used for hospital visits and rural health claims. It is characterized by including more procedure level reporting lines, as well as place for information such as hospital days.

HCPCS (HCFA Common Procedural Coding System)

codes used for supplies, materials and injections (i.e. bandages, rubber gloves, penicillin). These are reported in the same parts of insurance forms as CPT® codes (HCPCS as Level II CPT® codes). There are specialized HCPCS codes such as E, J and L codes used for specific procedures or services.

Health Summary

a patient summary of medical history including chronic medical problems, current medications, drug allergies and past medical, family and social history

Help Desk

service and support for the program

HITECH Act (The Health Information Technology for Economic Clinical Health Act)

According to Center for Medicare and Medicaid Services, “the Health Information Technology for Economic and Clinical Health (HITECH) Act provides HHS with the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health information technology (HIT), including electronic health records and private and secure electronic health information exchange.”

HPI (History of Present Illness)

the patient's description of related symptoms for today's visit. Often the HPI is noted in pre-defined documentation templates

HTN

abbreviation for hypertension or high blood pressure

Hx

the abbreviation for history or medical history

ICD-9 (International Classification of Diseases) Codes

diagnosis codes used by insurance companies. In order to get the best reimbursement, the code should be carried out to the 4th or 5th digit whenever possible

IDDM

the abbreviation for Insulin Dependent Diabetes Mellitus

Integration

allows the secure communication between two applications

Interoperability

the capability to provide successful communication between end-users across a mixed environment of different domains, networks, facilities and equipment

ISP (Internet Service Provider)

the company or service providing your Internet connection

LMP

the abbreviation for Last Menstrual Period

M.A. (Medical Assistant) or CMA (Certified Medical Assistant)

some clinics have similar positions known as Clinical Assistants. Responsibilities often include working up patients, triaging and returning patient calls and assisting the provider in general.

MD (Medical Doctor)

professional licensed to practice medicine

Meaningful Use

a set of standard enforced by the American Recovery and Reinvestment Act in addition to HIPAA standards and regulations

Medicare Locality

a US region (metro area, state, etc) defined by HCFA as having a particular cost structure. This affects reimbursement of fees because each is assigned a different GPCI weight.

Mid-level Practitioner

refers to the class of providers considered to be a level below M.D.s and D.O.s. (e.g. - Physician assistants (P.A.s) and Nurse Practitioners (N.P.s) )

Modifier

a two-character code added to a CPT® or HCPCS code that is used to help explain the procedure used for the reimbursement process. Up to 4 modifiers can be attached to each CPT®, although in most cases only 1 or 2 are used.

MPT

Master of Physical Therapy

N.P. (Nurse Practitioner)

is a mid-level provider that is required to have a Bachelor's degree and then attend a rigorous 3-year training program mainly instructed by advanced nurses. Must be supervised by a physician. NPs can specialize much like physicians can, but are somewhat limited (i.e. pediatrics, family medicine, etc.).

NIDDM (Non Insulin Dependent Diabetes Mellitus)

the most common type of diabetes and can be managed without insulin.

NKDA or NDA

No Known Drug Allergies

NPI (National Provider Identifier)

fairly new 8 digit alphanumeric identifier given to all medical facilities. Most M.D.s and DOS do not have NPIs at this time (they still use UPIN numbers). However, mid-level practitioners usually do.

NSF (National Standard Format)

standard format for electronic filing.

Objective

section in WebPT's Documentation record where the therapy staff documents their findings at a patient encounter. Consists of Exam findings, special tests, measurements such as strength, ROM, and flexibility results. The 'O' in SOAP note.

Office Visit Levels

also know as E&M codes, the code varies from level I to V depending on complexity with V being the most complex.

Outcome Measurement Tools

a measure of the quality of care; the standard against which the end result of the intervention is assessed; a requirement for all Medicare patients to be completed on evaluation and reassessed in subsequent follow-ups and upon discharge.

P.A. (Physician Assistant)

a mid-level provider required to have a Bachelor's degree and then attend a rigorous 3-year training program mainly instructed by physicians. They are not physicians, but in most states have similar rights and privileges. However, they must be supervised by a physician.

Past Medical History

a list of a past health issues, surgeries, specialists and other information shared by a patient about their past

Patient Demographics

the patient's basic administrative information such as name DOB, SSN, Insurance, Address, Etc.

Payor

any party responsible for payment of services rendered including the insurance company and patient

PCN

the medical abbreviation for penicillin

PCP (Primary Care Physician

the term used by insurance companies to describe the main provider that will manage a patient's health. In most cases this is a family practitioner, internist, general practitioner or pediatrician. The PCP is responsible for obtaining referrals to specialists as needed.

PDA (Personal Digital Assistant)

a hand-held device with a number of uses. Often allowing you to connect to the Web while mobile

PEFR (Peak Expiratory Flow Rate)

usually known as Peak Flow is the rate the air moves out of a patient's lungs at the beginning of the expiration, measured in liters per second

Plan

is the section in the documentation 'SOAP' note used to document the treatment the provider will prescribe including recommendations and any testing

Point and Click

activating a command by pointing a cursor or mouse to a certain area and clicking

Posting

the process by which patient charges are generated and payments are noted

PQRI Reporting (Physician Quality Reporting Initiative) -

the 2006 Tax Relief and Health Care Act required the establishment of a physician quality reporting system. CMS named this program the Physician Quality Reporting Initiative. The program is designed by CMS to improve the quality of reporting in the medical world. Even though it says 'Physician' in the title, Physical and Occupational Therapists can participate.

Practice Management

is a category of software used to manage the day-to-day operations of a medical practice. Practice Management software often includes scheduling, billing, reporting, and operational management for the practice.

Private Pay

is the industry reference for patients without insurance

Progress Note

the part of a medical record where healthcare professionals record details and document a patient's clinical status. PTs use this to update physicians on a patient's progress. A common format is the SOAP note.

Provider Login

consists of a login and password for providers to access their electronic medical records

Provider or Provider of Service

generally known title for MD, D.O., NP, or P.A.

Pull Down Menu

also called a drop-down menu is a menu or list of commands/options that appear when you highlight that area and a list for you to select from appears

Query

the process of retrieving information from a database through a search

RBRVS (Resource Based Relative Value Scale)

this is a scale of 'weights' assigned to particular CPT® codes that takes account of the relative amount of effort taken to perform a procedure based on the cost of supplies, the risk or difficulty and the time spent. The RBRVS is controlled by HCFA.

Referral

the recommendation of a medical professional to seek treatment from another medical provider. Some insurance companies require that on specific plans a referral must be obtained for certain procedures or visits to specialists. The referral consists of an authorization code, a number of visits allowed (if applicable) and an expiration date. This information can be stored and referenced in your EMR.

Referring Provider

the medical provider that referred the patient to another medical provider, often a specialist or for a specific procedure

Rendering/Performing Provider

the provider that is actually treating the patient

Risk Pool

when a group of practices come together for negotiating and contractual reasons (e.g. an IPA). A certain percentage of each amount reimbursed is withheld from the practice and put into a risk pool. This is used to cover unexpected expenses, but if it is not used, then it will be distributed back to the practices. The distribution structure is often based on productivity, profitability and other factors that make it a reward for more efficient operations.

ROI (Return on Investment)

measuring an increase in revenue or a decrease in expenditures based on a specific action

ROS (Review of Systems)

a series of questions related to the specific system or systems that the patient is having complaints about (i.e. respiratory for cold symptoms)

Rural Health Clinic (RHC)

is a health clinic that is contracted by HCFA to provide services to underserved populations. RHCs are reimbursed at a slightly higher level than the normal Medicare allowable. Usually clinics in outlying rural areas where the government needs to encourage practitioners to have clinics, although some 'rural' clinics are located in poorer parts of inner cities. RHCs are given a special status and when they bill particular procedures with QB (rural) or QU (urban) modifiers, they will get the higher rate. RHCs usually have to submit claims on a UB-92.

RVU (Relative Value Unit)

the weight within the RBRVS assigned to a particular CPT®. The Total RVU for a CPT® is made up of the Work RVU (the amount of time and effort it takes), the Practice Expense RVU (the overhead cost of that time), and the Malpractice RVU (the likelihood of complications),

SaaS (Software as a Service)

is a model of software deployment typically offered through a subscription where the user accesses the application on demand an application from a provider and the software is delivered on demand

Scalable

refers to how well software and/or hardware can adapt to an increase in demand and activity

Security

a system can only perform actions that are allowed by a specified user

Sever-based or Client-server

information is requested via a client program that sends a request to the server. The request is processed and sent back to the client program. The client program and the server must connect each time data is being transmitted. This usually requires a server to be located onsite.

Single Sign-on

the ability to sign in and identify yourself to access multiple systems without needing to enter multiple user names and passwords

SLP

speech language pathologist

SOAP Note

a commonly used progress note format that consists of Subjective, Objective, Assessment and Plan sections

Social History

a patient's social habits and history including marital status, alcohol and drug use and exercise habits

Subjective

the section in a documentation note where a patient's description of their current problem is documented. Consists of chief complaint, HPI and ROS.

Superbill (also known as an encounter form, route slip or fee slip)

a paper charge capture tool used to document coding for a specific patient visit. It is a printed form with patient information at the top, and a subset of the provider's/practice's most commonly used ICD and/or CPT® codes. The form travels with the patient through the clinic. Providers check off items when they see the patient, and the form then travels to the checkout desk or billing office where the codes are entered into the billing system.

Supervising Provider

the physician responsible for supervising patient care for a mid-level

Sx (symptoms)

the sensation or function the patient describes as experiencing

System Administrator

the EMR user or user group he user group that has the highest security level

Tablet PC

a computer that is much like a notebook or laptop but has the ability to digitize a written transcription or can use touch screen technology to access different areas without a keyboard or mouse

Template

often called a library or dictionary. Templates are a pre-defined selection of choices or fields designed to streamline the process of documentation

Till Reconciliation

a report used to balance what has been posted as money to be received against the actual monies/payments received

Time Grid

a provider's specific schedule for seeing patients that often includes how many appointments can be added to a day and how long should be allotted for each appointment slot

TOPS (Total Office Paperless Solution)

the act of using all electronic equipment to manage a clinic

Trial Balance

a detailed report of all invoices for a single patient

UPIN

a medical industry standard 6 digit alphanumeric identifier assigned to providers. Can be used for single provider or a group/facility.

Uptime

the average amount of time a system is functioning at full capacity and available for use

URI (Upper Respiratory Infection)

also known as the common cold

UTI (Urinary Tract Infection)

also known as a bladder infection

Wave Scheduling

the act of scheduling patients in waves. Patients rarely arrive on time, having blocks of busy and catch-up time can even this out. Modified wave scheduling is a more recent trend where the schedule is based around the actual time spent with patients. Most patient visits do not require the provider to be in the room with the patient for 100% of the time. Modified wave scheduling refers to creating a schedule that accounts only for the providers' time spent with patients.

Web-based

is in reference to an application that resides on a server that is accessible using a web browser and is made available from anywhere via the World Wide Web

WiFi

the local network that uses signals to transmit data wirelessly

Workflow Automation

the automation process of taking the document, information, tasks and action from one activity to another or from one person to another according to a set of pre-determined rules.

Heidi Jannenga PT

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